HESI RN
HESI Quizlet Fundamentals
1. A client with a diagnosis of anemia is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?
- A. White blood cell count.
- B. Hemoglobin and hematocrit.
- C. Platelet count.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct answer: B
Rationale: To evaluate the effectiveness of epoetin alfa (Epogen) in treating anemia, the nurse should monitor hemoglobin and hematocrit levels. These values indicate the oxygen-carrying capacity of the blood, which directly relates to the treatment of anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not specific indicators of the effectiveness of epoetin alfa in treating anemia.
2. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?
- A. Apply the restraints to ensure the client's safety.
- B. Reassess the client to determine if restraints are still necessary.
- C. Document the time the family departed and continue monitoring the client.
- D. Contact the healthcare provider for a new order.
Correct answer: B
Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.
3. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
- A. Loosen the right wrist restraint.
- B. Apply a pulse oximeter to the right hand.
- C. Compare hand color bilaterally.
- D. Palpate the right radial pulse.
Correct answer: A
Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.
4. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?
- A. I know you are capable of giving yourself the insulin.
- B. Giving yourself the injection seems to make you nervous.
- C. When I watched you give yourself the injection, you did it correctly.
- D. Tell me what you want me to do to help you give yourself the injection at home.
Correct answer: C
Rationale: Choice C is the correct answer because focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. By acknowledging the client's correct performance during the self-injection, the nurse can boost the client's confidence, encouraging him to assume total responsibility for the daily injections. Choices A, B, and D do not directly highlight the client's competence in self-administration, which may not be as effective in promoting independent self-care.
5. The nurse is providing discharge teaching to a client with a new prescription for warfarin (Coumadin). Which dietary instruction should the nurse include?
- A. Avoid foods high in vitamin K
- B. Increase intake of leafy green vegetables
- C. Consume a consistent amount of foods high in potassium
- D. Limit intake of high-protein foods
Correct answer: A
Rationale: The correct dietary instruction for a client taking warfarin is to avoid foods high in vitamin K. Warfarin is an anticoagulant that works by inhibiting vitamin K-dependent clotting factors. Consuming foods high in vitamin K, such as leafy green vegetables, can antagonize the effects of warfarin, potentially leading to treatment inefficacy or fluctuations in anticoagulation levels. Therefore, clients on warfarin therapy should be advised to avoid foods high in vitamin K to maintain the effectiveness of the medication. Choices B, C, and D are incorrect because increasing leafy green vegetables (choice B) would introduce more vitamin K, consuming a consistent amount of foods high in potassium (choice C) is not directly related to warfarin therapy, and limiting high-protein foods (choice D) is not a specific concern for clients on warfarin therapy.
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